CYBER KNIFE

The recent controversy regarding over treatment of prostate cancer, and the questioning regarding the usefulness of routine PSA testing is causing even more confusion in an
already confusing, and heavily nuanced, disease.  While there is undoubtably over treatment occurring because of the non specificity of the  PSA test, as well as the tendency for both patients and physicians to opt for an aggressive approach to dealing with prostate cancer, it’s not clear that “watchful waiting” is likely to always be as effective or harmless. The link below, for an article in the 11/15/2011 issue of the New York Times, outlines one NY physicians approach to “active surveillance”.  Unfortunately, while some of the dietary suggestions may or may not be helpful, and likely are for the most part harmless, recommending serial biopsies or an invasive, frequently imprecise  and questionable procedure such as cryosurgery in an 85 year old may not be, in my opinion, as effective and harmless as early and definitive noninvasive treatments, such as prostate stereotactic body radiosurgery (SBRT) with the cyberknife.

What is really necessary, is the realization that PSA is a test that must be interpreted in light of multiple other factors, and is not, in itself definitive.  We should be careful not to abandon screening and definitive treatment too quickly, rather that learning how to more carefully interpret PSA and other screening information in the most effective and safe way for each individual patient.

http://www.nytimes.com/2011/11/15/health/a-watch-and-wait-treatment-for-prostate-cancer.html?emc=eta1

James G Schwade MD FACR FACRO FASTRO
Executive Director,
Cyberknife Centers of Miami & Palm Beach

Surprisingly, there has remained controversy regarding the efficacy of breast irradiation following conservative surgery (“lumpectomy”) for early stage breast cancer. While the data has strongly supported the benefit, an article in this weeks Lancet,  would appear to finally settle the question and confirm the benefit of breast irradiation following conservative surgery. 

Today’s NY Times article is an excellent quick summary.

James G Schwade MD FACR FACRO FASTRO
Executive Director,
Cyberknife Centers of Miami & Palm Beach

In the accompanying link, researchers from the Mayo Clinic report the initiation of a clinical trial of vaccines against breast and ovarian cancer.  These vaccines are designed to be used in patients who disease has been treated and controlled, in order to prevent recurrence.  These, and other new approaches to control microscopic disease in cancer patients reinforce the importance, and probable future utility, of highly targeted focal irradiation, such as stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT), for which the Cyberknife is employed.  The use of these techniques, I believe, will become increasingly important and more useful as other effective systemic approaches to the control of microscopic disease are also developed.

View the article

James G Schwade MD FACR FACRO FASTRO
Executive Director
Cyberknife Center of Miami
Cyberknife Center of Palm Beach

CINCINNATI - When Greg Lester’s doctor told him he had prostate cancer, the Northern Kentucky resident didn’t shed a tear. Instead he and his daughter, Jennifer Haas, got busy researching the disease and the latest treatments available.

Their research led to a technology no local doctor offers but that is available in Columbus, Ohio and Lexington, Kentucky. It’s called CyberKnife.

Don’t let the name fool you. CyberKnife doesn’t cut. Instead of surgery, this is robot-driven, high-dose radiation. A machine adapted from car assembly lines moves around the patient, and radar-like pinpoint beams target the tumor only. Instead of the risks associated with surgery and the time it takes to recover from an operation, some patients report going from treatment directly to work. Doctors say the number of treatments is much shorter too. Rather than 40 or more sessions with standard radiation that would span more than two months, CyberKnife takes five treatments in one week.

Read more.

The CyberKnife Coalition (CKC) would like to inform you that Wisconsin Physician Services (WPS), the nationwide Legacy Part A Medicare contractor (formerly Mutual of Omaha Part A), has issued favorable coverage guidance for prostate SBRT.  This contractor recently retired its SBRT policy (LCD L26109) and replaced it with LCD L28366.  By updating its outdated Legacy Part A policy, WPS now has a consistent and favorable coverage policy in all states where it administers Medicare benefits.
 
The new SBRT LCD and a list of added diagnoses can be found on WPS’ website at the following html address: CLICK HERE 

This updated policy formalizes WPS’ positive position on prostate cancer previously stated in a Dec 2008 Communiqué that, at the time, only applied to its Legacy Part B states (WI, IL, MI, and MN) and J5 MAC jurisdiction (IA, NE, KS, and MO).  With this latest update, WPS has met its goal of establishing consistent and clear coverage for its providers nationwide. This decision by WPS is consistent with the growing payer acceptance and the trend toward coverage of CyberKnife. 
 
This policy change did not happen overnight and it did not happen without the efforts of our members who worked together to achieve this result.  The CKC will continue to work toward breaking down barriers that deny access to patients who would benefit from CyberKnife treatment. By doing so we hope patients treated with CyberKnife will be able to lead more fulfilling and healthy lives.  In the words of John Quincy Adams, “Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish”.  We hope you will persevere with us.  

The CyberKnife Coalition
Fighting Cancer with Medical Innovation

Spinal metastasis is a problem that afflicts many cancer patients. Traditionally, conventional fractionated radiation therapy and/or surgery have been the most common approaches for managing such patients. Through technical advances in radiotherapy, high dose radiation with extremely steep drop off can now be delivered to a limited target volume along the spine under image-guidance with very high precision. This procedure, known as stereotactic body radiosurgery, provides a technique to rapidly treat selected spinal metastasis patients with single- or limited-fraction treatments that have similar to superior efficacies compared with more established approaches.

This review describes current treatment systems in use to deliver stereotactic body radiosurgery as well as results of some of the larger case series from a number of institutions that report outcomes of patients treated for spinal metastatic disease. These series include nearly 1400 patients and report a cumulative local control rate of 90% with myelopathy risk that is significantly less than 1%. Based on this comprehensive review of the literature, we believe that stereotactic body radiosurgery is an established treatment modality for patients with spinal metastatic disease that is both safe and highly effective.

This review article was published in the International Journal of Surgical OncologyVolume 2011.

To view the complete review, please CLICK HERE…

CT screening of high risk individuals can cut the death rate from lung cancer by 20% compared with patients screened by chest x-rays.  However, the 40% incidence of false-positives can expose these patients to unnecessary or dangerous extra testing.  This point is made in an article in the most recent online issue of the New England Journal of Medicine (see link below).  While one never wants to alleviate one risk by imposing another, it’s important to keep the increased risk of complications from these extra tests in context.  Most of the invasive tests necessary, such as needle biopsies, carry some increased risk, but it’s well under 20%.  Importantly, while there is some increased risk to additional radiation exposure from additional x-ray studies.  However, the risk is, again, significantly smaller than the number of lives saved with CT screening.  It should be remembered that these are people with high risk for developing lung cancer.   But, we still need to work to better select the individuals to select for screening.

http://www.nejm.org/doi/full/10.1056/NEJMoa1102873?query=featured_home

James G Schwade MD FACR FACRO FASTRO
Executive Director,
Cyberknife Centers of Miami & Palm Beach

Clinical Prof. of Radiation Oncology &
Former Chairman,
Dept. of Rad. Onc., UM Miller Sch. of Med.

Clinical Professor, Dept. of Radiology,
FIU Wertheim College of Medicine

Adjunct Prof. of Biomedical Engineering
Dept. of Biomedical Engineering, FIU